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FAQs
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What are the basic types of back pain and what are their causes? What is the leading cause of chronic back pain? What is the most common use and when are epidural steroid injections indicated for back pain? Is there a limit to the number of injections you can have in a lifetime or in a year? Who is a candidate for facet injections? What is a Sympathetic Nerve Injection? What is a Trigger Point Injection? What is the difference between a sprain and a strain? What is degenerative disk disease? What is the difference between x-rays, MRI, and CT scan? Who is a candidate for radiofrequency? What is Percutaneous Disc Decompression? What are the basic types of back pain and what are their causes? There are many types of back pain and the causes of back pain can often be multi-factorial. There are simple types of back pain which are muscular causes, bony causes and disc causes. The muscular causes include muscle strain and sprain, most commonly caused by an imbalance where one group of muscles is more developed than another group of muscles. The bony causes include slippage of one vertebral body, that is, the bones of the back slip upon another. This is called spondylolisthesis, a malady is when the bones are actually misaligned. Discogenic causes are usually referred to as "slipped disc." These discs are cushions between two vertebral bodies, which can rupture or slip. They are structured much like a jelly-filled donut, and are "the shock absorbers of the spine." If the "jelly" comes out, the donut goes flat and it can no longer act as a shock absorber. This may result in severe pain, or what is commonly known as sciatica or nerve impingement. This jelly that is inside the disc contains some extremely powerful enzymes that can cause terrible inflammation on the nerves if the nerves come in contact with this. These enzymes can also cause back pain as well as nerve pain. Because of this irritation or inflammation that the disc is causing, we use drugs to stop inflammation. Many times we use orally taken non-steroidal anti-inflammatory medications or steroid medications. These three types of back pain - muscular, bony and disc - comprise the vast majority of back pain What is the leading cause of chronic back pain? Most frequently, it is muscular. This is why physical therapy is such an important adjunct to invasive pain management and oral medication. Physical therapy re-educates the patient and strengthens the muscles in the back so that the patient can be restored towards normalcy and at the very least minimize their pain. How can a patient tell when the back pain is due to muscular pain or due to a much more serious condition like discogenic pain? If the patient is lifting something too heavy, jerks and suddenly feels a "pop" in their back with pain shooting down the leg, this is most not muscular pain. This patient should go immediately to a physician speacializing in pain management. The physician will likely examine the patient and perform a straight leg test which will or will not cause pain, obtain a MRI or a CAT scan to actually visualize the discs radiographically, or the physician may perform a electromyogram. This is usually a test performed by a neurologist or a physiatrist that can delineate whether there is an electroconduction problem down the nerve. All of these things - the history, the physical, the MRI testing and the EMG testing - better enable the physician to tell what type of pain the patient is suffering from and what is the etiology of their pain. Once the etiology is accurately obtained, then and only then can the physician form a treatment plan which is proper for that patient. What is the most common use and when are epidural steroid injections indicated for back pain? Steroids are anti-inflammatory drugs, so they are only indicated where there are conditions of inflammation. The steroid medication is injected percutaneously into the epidural space in a wide variety of fashions under fluoroscopic guidance. This is a fancy X-ray machine in an operating room where the medication can be placed exactly where the inflammation is believed to be. This fluoroscope also minimizes any of the complications that can occur by placing the needle blindly into the spine. The advantage of delivering epidural steroids is that the physician can deliver a high enough concentration in and around the inflamed area much greater than we could have obtained if the medication was given orally. Epidural steroid injections have been in use since the early 1960's and have been well studied and well published in the medical literature. They have been proven effective since that time. Is there a limit to the number of injections you can have in a lifetime or in a year? The number of injections is deliberately limited based on the experience of the medical profession since the 1960's. Generally speaking, if we don't get very good relief in two to three weeks with two to three injections, the patient will most likely not get substantial relief just from epidural injections. There are occasions however where we can vary the type of injection which is given and we will go to a fourth or fifth injection. Generally speaking it is the total dose of steroid a patient receives that actually limits the number of injections the patient can receive. When steroids are delivered to the body, we can develop some side effects from the steroids. This is a complex problem of endocrinology which can cause increased blood sugar or retention of fluids to name a few. Who is a candidate for facet injections? Anyone with persistent neck or back pain, who has not responded to epidural steroid injections or conservative therapies (i.e. chiropractor, anti-inflammatory medications, physical therapy). How is the injection performed? Facet injections are safely performed on an outpatient basis. After sterilizing the area, a small amount of local anesthetic is used to numb the skin. Needles are then placed through the numb area to the desired locations using real-time x-ray (fluoroscopy) to ensure precise placement. A small amount of local anesthetic is injected and the needle is withdrawn. The procedure itself typically takes 15 minutes followed by a short observation period. What is a Sympathetic Nerve Injection? A lumbar sympathetic nerve injection can be used to treat and diagnose Reflex Sympathetic Dystrophy (Chronic Regional Pain Syndrome), vascular insufficiency of the lower extremity, Herpes Zoster, Post Herpetic Neuralgia of the lumbar area, phantom limb pain, and stump pain. Wear loose comfortable clothing, and bring someone with you who will drive you home after the procedure. Lumbar sympathetic blocks are usually performed in the office where x-ray equipment is available to verify placement of the needle. Patients are placed in the prone position (face down). The skin is washed with a sterile prep. Local anesthetic is injected into the skin. The physician will insert a needle at the L2-3 level. Placement is confirmed with x-ray and x-ray dye. Local anesthetic is then injected through that needle. After the procedure, the temperature of the lower limb on the injected side rises. The extremity will return to normal color and the pain may be dramatically decreased. Your reaction to the injection will be important in diagnosing your pain and planning your treatment. What is a Trigger Point Injection? When you pull the trigger on a gun, a small action of the finger, a large reaction occurs as the bullet explodes out of the gun barrel. In a similar way there are medical conditions in which a small abnormal area of muscle or connective tissue can trigger a large pain reaction. This area is called a trigger point (TP). It is usually caused by an injury but not always. A TP is thought to start with an inflammatory process which constantly stimulates the nerves, creating pain. Once we experience pain, our body mechanics change, perpetuating a cycle of muscle disuse and deconditioning. Injection of the TP area with a local anesthetic and a small amount of anti-inflammatory steroid usually breaks this cycle and leads to relief. Usually a repeat injection, sometimes two to three in a one-month period, is planned. Each injection requires only a few minutes, once the trigger points are found. Most commonly TPs occur in the shoulder area and in the muscles of the back. Complications of injection are very rare. A gradual increase in activity will usually aid in recovery after successful TP injection. What is the difference between a sprain and a strain? A strain occurs when a muscle is stretched or torn. A sprain occurs when a ligament is stretched or torn. Strains are often the result of overuse or improper use of a muscle, while sprains typically occur when a joint is subjected to excessive force or unnatural movements (e.g., sudden twists, turns, or stops). Sprains can be categorized by degree of severity: • A first-degree sprain stretches the ligament but does not tear it. Symptoms include mild pain with normal movement. • A second-degree sprain is characterized by a partially torn ligament, significant pain and swelling, restricted movement, and mild to moderate joint instability. • In a third-degree sprain, the ligament is completely torn with mild to severe pain, swelling, and significant joint instability. What is sciatica?In the low back, nerves join to form the sciatic nerve, which runs down into the leg and controls the leg muscles. Sciatica is a condition that may cause radiating pain, numbness, tingling, and/or muscle weakness in the leg but originates from nerve root impingement in the lower back. Nerve impingement is most often caused by a herniated disk or spinal stenosis. What is spinal stenosis? Stenosis refers to a narrowing of the spinal canal, usually in the lower back (lumbar) region. This narrowing is often a result of the normal degenerative aging process. It occurs as the disks of cartilage that separate the spine's vertebrae lose water and the space between the vertebrae become smaller, causing friction between the bones. The loss of water in the disks makes them less flexible and unable to act as shock absorbers in the spine. Daily wear and tear on the spine becomes more significant without these shock absorbers. As the disks degenerate, vertebrae may shift, causing the spinal canal to narrow. In some cases, the nerves that travel through the spinal column to the legs become squeezed. This can cause back and leg pain. Arthritis and accidental falls also contribute to the narrowing of the spinal canal, this will lead to compression of the nerve roots causing pain and discomfort. What is degenerative disk disease? Degenerative disk disease is a general term applied to back pain that has lasted for more than three months. It is caused by degenerative changes in the intervertebral disks in the spine and can occur anywhere in the spine: low back (lumbar), mid-back (thoracic), or neck (cervical). Under the age of 30, these disks are normally soft, and they act as cushions for the vertebrae. With age, the material in these lumbar disks becomes less flexible and the disks begin to erode, losing some of their height. As their thickness decreases, their ability to act as a cushion lessens. The less dense cushion now alters the position of the vertebrae and the ligaments that connect them. In some cases, the loss of density can even cause the vertebra to shift their positions. As the vertebrae shift and affect the other bones, the nerves can get caught or pinched and muscle spasms can occur. Degenerative disk disease is primarily a result of the normal aging process, but it may also occur as a result of trauma, infection, or direct injury to the disk. Heredity and physical fitness may also play a part in the process. What are muscle spasms? When muscles become inflamed, they can also spasm, or contract tightly, as a response to injury. While they are the body's way of protecting itself from further injury, they often produce excruciating and often debilitating pain. Muscle spasms are common in the low back (lumbar) muscles. What is the difference between x-rays, MRI, and CT scan? X-rays are a type of radiation, and when they pass through the body, dense objects such as bone block the radiation and appear white on the x-ray film, while less dense tissues appear gray and are difficult to see. X-rays are typically used to diagnose and assess bone degeneration or disease, fractures and dislocations, infections, or tumors. Organs and tissues within the body contain magnetic properties. MRI, or magnetic resonance imaging, combines a powerful magnet with radio waves (instead of x-rays) and a computer to manipulate these magnetic elements and create highly detailed images of structures in the body. Images are viewed as cross sections or "slices" of the body part being scanned. There is no radiation involved as with x-rays. MRI scans are frequently used to diagnose bone and joint problems. A computed tomography (CT) scan (also known as CAT scan) is similar to an MRI in the detail and quality of image it produces, yet the CT scan is actually a sophisticated, powerful x-ray that takes 360-degree pictures of internal organs, the spine, and vertebrae. By combining x-rays and a computer, a CT scan, like an MRI, produces cross-sectional views of the body part being scanned. In many cases, a contrast dye is injected into the blood to make the structures more visible. CT scans show the bones of the spine much better than MRI, so they are more useful in diagnosing conditions affecting the vertebrae and other bones of the spine. What is physical therapy? Physical therapy is the treatment of musculoskeletal and neurological injuries to promote a return to function and independent living. Physical therapy incorporates both exercise and functional training. Exercise restores motion and strength while functional training facilitates a return to daily activities, work, or sport. What is radiofrequency? Radiofrequency is a safe and effective technique used in pain management to desensitize specific nerves and reduce pain impulses using radiowaves. It is used to treat certain neck, arm, back or leg pain problems after the cause of the pain has been identified. Who is a candidate for radiofrequency? People with persistent neck, arm, back or leg pain, with specific nerves or joints that have been identified as causing their pain. Diagnostic blocks, with local anesthetic, have been performed prior to the use of radiofrequency to ensure that the correct origin of the pain is located. How is radiofrequency performed? Radiofrequency is performed on an outpatient basis with the availability of monitoring and sedation. After sterilizing the area, a small amount of local anesthetic is used to numb the skin. Small needles are then placed through the numb area to the desired locations using special real time x-ray (fluoroscopy) to ensure precise placement. A probe, attached to a radiofrequency generator, is passed through the needle and produces radiowaves that desensitize the desired nerves. The procedure itself takes less than 30 minutes, followed by a short observation period. What is Percutaneous Disc Decompression? Percutaneous Disc Decompression procedure is indicated in patients who are suffering from pain, numbness or disability resulting from a bulging or herniated lumbar disk. Most often, these patients are presenting with pain in the lower back, which may be radiating into either leg and foot, or both, and is often associated with numbness. It is indicated in certain patients with low back pain only, after further diagnostic testing. Similarly, it may be appropriate in patients with leg pain only, resulting from an abnormal lumbar disk. The appropriate diagnostic evaluation prior to this procedure will nearly always involve a cervical or lumbosacral spine MRI as well as complete history and physical examination. If the pain is limited to the lower back without obvious radiation into the legs, discography or injection of contrast dye into the disk to further elucidate the pain mechanism may be required. The extent of disk bulge or herniation must be modest, as large herniated disks may not respond well to this treatment. On the other hand, it should be noted that patients with small bulging or herniated disks may benefit more from this non-invasive treatment than from a surgical approach to treating their disk abnormality. Nucleoplasty uses a coblation technology, which utilizes radiofrequency energy to ablate tissue inside the disk resulting in decompression of the disk and thermal alteration of the tissue. This effectively reduces the extent of disk protrusion, as well as desensitizing the disk itself. The resultant pain relief should be obvious within several days after the procedure and the pain associated with the procedure itself is quite minimal. The procedure is done through a needle that is placed into the herniated disc after numbing the skin. Real time X-ray guidance is used to properly locate the needle tip inside the abnormal disk and contrast dye may be injected to confirm optimal placement. A wand is placed through the needle, to generate radio waves that dissolve excess disk tissue, reducing the size of the disk. This relieves the pressure in the disk and on adjacent nerves. This procedure is done on an outpatient basis with minimal recovery necessary and with very low incidence of complications. The result is disk decompression and pain relief, accomplished without surgical intervention and with far less opportunity for complication or need for rehabilitation. DeKompressor technology reduces the herniated disc by removing tissue using a rotary action through a needle. This achieves similar results to Nucleoplasty, effectively creating a space or vacuum effect within the disc, pulling the herniation or bulge backward. Hydrocision uses a probe placed through a needle which generates a high pressure water stream; effectively eating the internal disc material which is then removed through a separate port in the probe. The herniated disc is then decompressed. |